Houston proposes sharp hike in ambulance fees

1of2EMTs with the Houston Fire Department prepare to leave after loading a patient into an ambulance while responding to a 911 call Friday, May 15, 2015. ( Melissa Phillip / Houston Chronicle )Photo: Melissa Phillip, Staff

2of2A woman is placed in the back of an ambulance after a "carbon monoxide incident" at a business in the 3100 block of Produce Row in June.Photo: Jay R. Jordan

Houston Fire Department leaders on Tuesday proposed a sharp hike in ambulance fees, floating several new charges they hope will prevent repeat callers from using the city’s emergency medical services as a convenience.

Ambulance transport fees would rise 70 percent, to $1,876; the accompanying $14.36-per-mile fee would not change. Aside from annual adjustments for inflation, it would be the first increase in the fees in six years.

“In essence, the taxpayers of the city of Houston are subsidizing every medical transport call,” Fire Chief Sam Peña told a City Council committee Tuesday. “We are not recouping what we incur to deliver that service.”

Houston also would levy new fees in cases when paramedics respond — at an estimated cost of $1,400 per trip, $1,800 if transport to a hospital is required — but the city currently recovers none of the cost of sending them.

The proposed fees include a $365 charge when a patient dies at the scene; a $175 charge when a caller’s only request is to be moved, such as after a fall at home or at a nursing home, or when a resident wants to be moved from a wheelchair to a bed; and a $175 fee when a caller is treated at the scene and does not need to be transported to a hospital, such as when a diabetic patient needs insulin or, Peña grumbled, when a caller complains that a two-week-old bee sting is itching.

HFD leaders hope the latter fees spur residents and staff at nursing facilities to rethink what constitutes an emergency that requires a call to 911, and to better grasp the difference between the city’s trained paramedics and the purely transport role provided by private ambulance companies.

Nearly 30,000 times in the fiscal year that ended last month, Houston paramedics responded to 911 calls that did not require the callers to be taken to a hospital, Peña said. Falls, he added, are the sixth-most common call the department receives.

“We’re targeting the habitual people that call us day in and day out to move them from the bed to the wheelchair and two hours later they call us back to move them from the wheelchair to the bed,” HFD Assistant Chief Justin Wells said. “This spurs a discussion. These people that call routinely out of convenience instead of emergency, this might change their behavior.”

Mike McEvoy, who chairs the International Association of Fire Chiefs emergency medical services section, said about a third of U.S. metropolitan departments have instituted such fees, and he expects 90 of all EMS services to follow suit within a decade. However, he said, these charges have not yet driven a clear shift in callers’ behavior.

“It really hasn’t done anything in communities where they said, ‘We’ll institute that charge and it will lower those calls,’” said McEvoy, who also serves as EMS Chief for Saratoga County, N.Y. “A fact of being in this business is that there’s a fair number of people that, without the ability to pay, they just won’t.”

Still, he added, “It’s becoming such a huge burden on a lot of the systems that somehow they have to start to recoup some of those expenses.”

Houston issues about $110 million a year in ambulance bills and collects about 40 percent of that.

A third of Houstonians who call 911 have no insurance, and the city collects almost nothing on those trips. About half of callers have federally funded health care, and the city collects about a third of what it bills the Centers for Medicare and Medicaid Services in those cases. Thirteen percent of Houston EMS patients have private insurance, and the city collects 70 percent of those bills.

Whether the new fees change the behavior of callers who may never pay them, McEvoy said, Peña’s proposal makes sense in part because Medicare and Medicaid reimbursements are based on the average EMS rates in each region. If HFD is not billing enough to cover its own costs, that forces all local taxpayers to provide an even bigger subsidy for each ambulance trip.

Peña said he expects to collect $1 million more annually under the new fee proposal. However, if Medicare and Medicaid reimbursements rise as a result and private insurers follow suit, Wells said the additional revenue could run into the tens of millions.

“CMS will set their reimbursement rates based on what’s usual and customary in the region. The Houston Fire Department is the 800-pound gorilla in this region,” Peña said. “By us keeping the rates that we charge arbitrarily low, we are not providing any incentive for Medicare-Medicaid to raise their reimbursement rates.”

The city’s proposed ambulance transport fee would be the highest among the nine cities surveyed by PFM, a financial consulting firm the city hired to produce a long-term plan last year. McEvoy, however, said Houston’s proposed fees are in line with those he sees across the country, if not a bit on the low side.

City Council members on Tuesday generally agreed with Peña’s view that the city must recoup its costs and encourage people to call 911 only for serious matters. Some also backed the new fees.

“If a resident falls in an assisted-living, for-profit organization, those employees of that assisted living facility are directed not to pick up the patient for liability and workers’ comp issues. So, guess who goes and picks up the patient? The Houston Fire Department,” Councilman Dave Martin said. “There has to be a change in behavior there.”

Other members worried, however, that the proposal would not have the desired effect. Councilman Robert Gallegos was concerned the fee too often would fall on elderly residents, in fragile health and on fixed incomes. When Councilman Mike Knox learned the fee for paramedics to help a nursing home patient back into bed would be assessed to the patient and not the facility, he questioned the logic of the proposal.

“If it’s the patient, the company isn’t going to change. The only person who’s going to care is the elderly person who keeps falling out of her bed,” he said. “Where’s the benefit to the citizens of that?”

The calls for which no hospital trip is required could be treated like false fire or burglar alarms, Knox said, with fees levied only after repeated calls. The fees could be assessed differently on residential and commercial callers, as city water rates are, Councilwoman Brenda Stardig suggested, to better target nursing homes with repeated calls for service.

Peña and Wells said they would revisit both points with city legal staff.

Mike Morris has covered City Hall for the Chronicle since early 2013, having covered Harris County government for two years prior to that. Before coming to Houston, he covered local government, agriculture, business and sports at daily and weekly newspapers in southern Indiana and central Ohio. He covers all things policy and politics in the nation's fourth-largest city, explaining the roots of today’s complex problems and exposing public corruption and failing programs. In 2012, he won the Texas Associated Press Managing Editors’ annual Freedom of Information award and was a Livingston Award finalist for a series of stories documenting rampant mismanagement at the Harris County Housing Authority.